Many patients express the preference to be safe rather than sorry if there is any risk of a lesion being a melanoma.
“That desire should be considered when evaluating the results of the two studies just discussed. Would a patient who would rather be safe than sorry think that a risk of 1 in 24 for the excision of a small-diameter lesion was appropriate if he or she was also given the information that the diagnosis of more than one in four small-diameter melanomas may be missed?” he asked.
Studies show that patients find their melanomas more often than physicians do. Unfortunately, the lesions found by patients are likely to be deeper or more advanced than those that physicians find. “The fact that patients would monitor for smaller lesions and start the process of getting in to see the doctor to get a lesion checked as early as possible could hopefully avoid what could end up being a critical delay in the recognition of a melanoma,” he said.
Dr. Goldsmith next addressed lesion darkness. “The single criterion that seems to have the most impact on recognition of the smallest melanomas is the criterion of darkness,” he said.
The singular importance of darkness for the diagnosis of small-diameter melanomas has been described in several series (Tumori 2004;90:128–31; J. Eur. Acad. Dermatol. Venereol. 2007;21:929–34; and Arch. Dermatol. 1998;134:103–4). These reports suggest that, “when evaluating a lesion of unknown history, an 8-mm lightly pigmented macule with symmetric variation in pigmentation—two of the four current ABCD features—is of less concern than a 3-mm, circular, evenly pigmented black macule or papule with none of the four current ABCD criteria,” said Dr. Goldsmith.
In other words, the criterion of darkness is a stand-alone, nonredundant feature to help recognize melanomas. “It just doesn't make sense that darkness is currently not even one of four objective criteria used in educational strategies related to melanoma recognition,” he said.
Dr. Goldsmith also provided evidence that increased emphasis on the criterion of darkness enhances other strategies to diagnose melanomas, including early recognition of asymmetry in melanomas (Arch. Dermatol. 1994;130:1013–7), recognition of change in melanomas (Br. J. Dermatol. 1999;141:783–7), and identifying small “ugly ducklings” that are melanomas (Arch. Dermatol. 1998;134:103–4).
“Changing the D from diameter to dark would accomplish two goals: We would not deter the recognition of smaller melanomas, and we would educate patients and the public about how to recognize many smaller lesions of concern,” he said. This change would represent a true evolution of the ABCDE criteria, he added.
Changing the criteria “would not deter the recognition of smaller melanomas, and we would educate patients and the public about how to recognize many smaller lesions,” Dr. Stuart Goldsmith said.
Source Courtesy Dr. Stuart Goldsmith
Lesions found by patients are likely to be deeper or more advanced than this melanoma in-situ with a mixed pattern.
Source Courtesy kimggraphics